Friday, August 22, 2014
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How to prevent yourself from getting the wrong prescription

Occasionally, things go wrong when prescriptions are being prepared at the pharmacy. For example, one person's medicine may be placed into a bag that is labeled with someone else's name. Or a label prepared for a prescription may be mistakenly placed on a bottle containing another person's medicine.

How to prevent yourself from getting the wrong prescription

Occasionally, things go wrong when prescriptions are being prepared at the pharmacy. For example, one person's medicine may be placed into a bag that is labeled with someone else's name. Or a label prepared for a prescription may be mistakenly placed on a bottle containing another person's medicine.

Another reason that a patient might receive a medication intended for another patient is often because the patient was not properly identified before the medication was given. For example, if the pharmacist identifies the patient only by name it can cause a mistake if there is another patient with the same or similar name is listed in their computer system or their prescription bag is also ready for pick-up. Also, patients who are confused or hard of hearing might answer "yes" even if they are called by the wrong name.

One of the most important things you need to do when picking up medicine from the pharmacy is to confirm that what you’ve been handed is actually for you.   

This past week we heard from a woman who pinched her finger in a folding leg of a table and also dropped the table. Her finger was bleeding and the pain that was so bad that she decided to go to the hospital ER. It turned out that a dislocated finger needed to be adjusted and she also needed several stitches.

Before the patient left the ER she was handed a prescription for Tylenol with Codeine for the pain. She got the prescription filled at a nearby pharmacy and received a small bag with the pills inside, saw her name on the bag and signed for it. At home she took a few doses of the medication but had no relief from the pain. Inspecting the container more closely, she noticed that that it was labeled “lisinopril for blood pressure” and it also had someone else’s name on it. She immediately notified the pharmacy. Guess what?  The pharmacist admitted that another patient was given her Tylenol with Codeine. Fortunately neither patient was harmed by the drug error.

In another case, a mother picking up a prescription for her son was supposed to receive methylphenidate for attention deficit hyperactivity disorder (ADHD). Instead she was given a heart medication intended for another patient. The mother noticed the error because the pharmacist mentioned the medicine was for “chest pains.” It turned out that the two patients had the same name.

Most errors are noticed during the pharmacy checking process. However, if they are missed, mistakes like these could result in someone receiving a medicine that was intended for someone else, which obviously could cause harm.

You can help to make sure that the medicine you receive at the pharmacy is intended for you by remembering the following tips.

  • Always identify yourself, using your full name, before you accept any medication or before any health-related procedure. When requesting or picking up your prescription or refill at the pharmacy, always provide at least 2 pieces of information that identify you. For example, in addition to your name, also give your address or date of birth.
  • Always check your medicine before leaving the pharmacy counter. Research we completed last year shows that over 50% of wrong patient prescription errors can be stopped simply by the patient confirming that it’s their name typed on the prescription container. So don’t overlook the importance of the label check at pick up.
  • Be familiar with the names of your medicines, why you take them, and how you take them. It’s important for pharmacists to provide drug information when you pick up your prescriptions. So always ask your pharmacist to explain what the medicine is used for and to review the instructions on the label with you. Check that the medicine is the one your doctor or other healthcare provider prescribed for you. If any of the information is different from what you were expecting, tell the pharmacist. Make sure that your concerns have been addressed before you take the medicine.

Following these simple steps can help to ensure that the prescription you pick up from the pharmacy is the right medicine, not someone else's.


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Michael R. Cohen, R.Ph. President, Institute for Safe Medication Practices
About this blog

Check Up covers major health events in our region and offers everything from personal health advice to an expert look at health reform. Read about some of our bloggers here.

For Inquirer.com. Portions of this blog may also be found in the Inquirer's Sunday Health Section

Michael R. Cohen, R.Ph. President, Institute for Safe Medication Practices
Daniel R. Hoffman, Ph.D. President, Pharmaceutical Business Research Associates
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